Holistic Health Care
What is it, and how can we achieve it?
Derick T Wade
Professor and Consultant in Neurological Rehabilitation
Oxford Centre for Enablement,
Windmill Road, Oxford OX3 7LD, UK
Tel: +44-(0)1865-737306; Fax: +44-(0)1865-737309;
email: derick.wade@noc.nhs.uk or derick.wade@ntlworld.com
Summary
This paper develops a systematic and logically consistent model of holistic healthcare. Holism
refers to an approach to health which acknowledges that health depends upon many interrelated components which interact in such a way that the overall effect constitutes health (or
illness). The current understanding of illness is, in contrast, linear and reductionist. It assumes
that all illness starts with a disorder within the body causing bodily symptoms that lead on to
disability and restrictions on social life. This is the biomedical model. This paper demonstrates
that this model is flawed in several ways: the underlying assumptions are false, it cannot explain functional (so-called non-organic) illnesses which are common, and it does not lead to
well-managed healthcare systems. The biopsychosocial approach to illness is then explored,
with a detailed description of one specific model based on the model underlying the World
Health Organisation’s International Classification of Functioning. The model is expanded to
recognise four systems centred on the person – organs, the whole person, behaviour, and social
role function – and four contextual factors that influence these systems – personal factors,
physical environment, social environment, and time. The new model also draws attention to
two important components of any holistic model of health, choice (free-will) and quality of life.
Illness is then shown to be a socially determined state whereby the patient may initiate being ill
but it requires others, usually healthcare professionals to validate illness before it is fully accepted. The paper then emphasises some lessons that follow from this model, illustrating its
utility. Finally there is an analysis of healthcare which emphasises that healthcare is an active
problem-solving process. The implications of the holistic model of health care both for clinical
care and for the management of healthcare systems are then discussed, emphasising the complex nature of healthcare and the social aspects of illness. The important overall conclusion
from this paper is that health and illness should be seen as socially construed states that involve
a whole person in their own context, and that effective health care requires both a full analysis
of a person’s illness to identify all factors relevant to its genesis and a wide range of interventions across several domains. In people with complex or long-term conditions effective management will usually require many interventions delivered by different organisations, including
those outside normal healthcare, over a long time. This requires a new approach to the management of healthcare systems. This new model is one of the first explicit descriptions of an
approach to holistic healthcare; it can certainly be improved.
Holistic health care. Derick Wade.
November 25th 2009.
Introduction
Holistic health care is perceived to be good,
both morally and practically but it is difficult to find either any clear enunciation of
what constitutes holistic healthcare, or any
clear explanation of its practical utility.
This paper aims to overcome these difficulties.
This paper first considers what holism is
and then considers what a holistic approach
to illness might be, and how this might improve healthcare. Although the paper is
concerned with a philosophical analysis of
the problems, it does also consider the evidence that supports the holistic model of
health proposed. It also derives some practical conclusions in relation to both the clinical care of an individual and the delivery of
services to large groups. The underlying
theme is that illness is a socially determined
state, not a biologically determined state
and that healthcare is consequently a socially determined process.
Almost all healthcare practitioners would
now claim to practice holistic healthcare.
This applies not only to the United Kingdom’s National Health Service (NHS) and
traditional healthcare professions but to almost all practitioners of alternative health
care. Indeed no-one would admit or agree
that their personal, professional or organisational practice was not holistic.
At the same time, few if any of these professions, people or organisations make it clear
what they mean by ‘being holistic’. They do
not provide any definition, or examples of
how they manifest their holism. It is difficult to discover any criteria against which
their success at being holistic could be
measured. Indeed after searching using
Google I could not find any sites that reported how holistic their practice was, let
alone how the proponents measured it. I
doubt that many of the people, professions
or organisations actually have any clear
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conceptual understanding of what they
mean by ‘being holistic’.
Politicians are equally prone to using the
word. On March 11th 2004 the Right Honourable John Reid, then the UK Secretary of
State for Health stated in a speech: “The
NHS must focus on good case management
where patients with complex needs are identified
and supported by skilled staff working in a holistic fashion in an integrated care system.”
But he failed to indicate either what he
meant by this or how he intended to measure this. And this was at a time when the
NHS was being given targets for everything,
with precise measures!
Given this widespread use of the word, holistic, in relation to healthcare and given the
assumption that holistic healthcare is morally and practically good, it is important to
consider in some detail what the term might
mean before progressing.
Holism – origins, development, healthcare
The concept of holism may have a long history, but the word itself was coined by Jan
Smuts in 1926 and was first published in his
best-selling book, ‘Holism and Evolution’
[1]. The book is still in print, and a copy of
the second edition (1927) is available for
download on the Internet [2].
Jan Smuts (1870 – 1950) was a polymath. He
started as a soldier fighting against the British in the Boer War but he later became a
General and then a Field Marshall in the
British Army. He also became a powerful
politician and was twice the South African
prime minister (1919-24; 1939-1948). He also
had much wider interests and was a lawyer
and a philosopher. It was as a philosopher
that he wrote this book.
Jan Smuts defined holism thus: “The tendency in nature to form wholes that are greater
than the sum of the parts through creative evolution.” I assume that he chose the word to
Holistic health care. Derick Wade.
November 25th 2009.
sound like ‘whole’ and that he deliberately
left out the ‘w’ when writing the word.
The concept of holism was a part of a development in thinking in the twentieth century
that led on to General Systems Theory [3]
and later to theories of complexity and
chaos. These theories are especially relevant
in health care where the importance of complexity (as a mathematical phenomenon) increasingly recognised [4][5][6].
Complexity emphasises that in many systems relationships are not linear so that, for
example, it cannot be assumed that there
will be a simple relationship between cause
and effect. Complexity should be distinguished from complicated, which may just
mean difficult to understand or having
many factors.
Holism has become increasingly popular
within health care. There are now many associations and societies concerned specifically with holistic health care such as:
• British Holistic Medical Association [7]
• American Holistic Medical Association
[8]
• American Holistic Health Association [9]
• American Holistic Nurses Association
[10]
Holistic medicine was a phrase first used in
1960 by F H Hoffman [11] who wrote about
“.. concern with teaching about the whole man –
‘holistic’ or comprehensive medicine ..”. This
implies that holistic is synonymous with
‘comprehensive’ but he gave no further
definition. A later article by R W Menninger
was a little more explicit: “… holistic medicine that integrates knowledge of the body, the
mind, and the environment …” [12].
Another more recent definition – one of
many similar statements found on the Internet – is that given by the American Holistic
Medicine Association: “Holistic medicine is
the art and science of healing that addresses
the whole person - body, mind, and
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spirit. The practice of holistic medicine integrates conventional and alternative therapies to
prevent and treat disease, and most importantly,
to promote optimal health. This condition of holistic health is defined as the unlimited and unimpeded free flow of life force energy through
body, mind, and spirit.” [8].
These definitions are imprecise and do not
lead to any criteria for measuring how holistic an approach is. It is difficult to discover
well justified and agreed definitions or explanations of holistic medicine, just as it is
difficult to find any clear exposition of its
alleged polar opposite, the “Medical model”
of illness [13].
The term, holistic medicine now seems to
encompass two separate concepts. The first
concept is close to the original meaning, referring to a comprehensive analysis of illness, considering the whole system. It recognises that illness (being sick) is a human
phenomenon, and that a full understanding
and analysis of illness requires a broader
perspective than simply focusing on disease.
The other more recent meaning attached to
holism is that of using an ‘alternative’ approach – that is, alternative to the traditional biomedical approach to illness. There
is usually also an implication that the approach being proposed is a morally better
approach to illness, but rarely do the practitioners specify what they mean by holistic
or how their practice manifests it.
In summary, holistic healthcare refers to an
approach to analysing illness and providing
healthcare that acknowledges and responds
to all factors relevant to the health (or illness) of a person. The term itself does not
signify what those factors are or how they
are classified. The word holistic is also used
to suggest a morally better and often an alternative non-allopathic treatment approach
to illness. I will not consider this second
meaning any further.
Holistic health care. Derick Wade.
November 25th 2009.
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Models of illness
A holistic approach to illness depends crucially upon using a model of illness that includes all the relevant components or factors.
lar model or theoretical basis used by the
profession or organisation and the standard
holistic model of illness. This obviously depends upon the organisation explicitly formulating the theoretical basis of its practice.
A model is defined well by the Oxford English Dictionary (2006): “A simplified or idealized description or conception of a particular system, situation, or process that is put forward as a
basis for calculations, predictions, or further investigation.” In other words it is an abstract
method for describing and analysing the relationships between different factors which
contribute to the outcome of interest. Its
utility is in allowing prediction of the effects
of changing a factor, for example treating a
disease to cure illness.
In fact very few organisations or professions
or individuals do specify the theoretical basis for their practice. A search of the UK
Department of Health website does not reveal any discussion of the model of illness
that underpins their decisions. Indeed I
have not found any explicit statements by
organisations commissioning (purchasing)
healthcare or by organisations supplying
healthcare, setting out how illness is analysed or conceived by the organisation.
In the context of health and illness a model
will:
• Specify what factors are of importance
in determining whether a person is ill
(and conversely, by implication, what
factors are not relevant)
• Specify the nature of the interrelationships between these factors and
being ill.
Further, a holistic model of illness will be
one that:
• Identifies all the major factors relevant
to the causation and understanding of
illness
• Predicts or explains observed interrelationships and other phenomena concerning illness
• Acknowledges explicitly the perceptions
and experiences of the ill person (i.e. be
person-centred).
An agreed holistic model of illness is needed
so that anyone can judge whether a particular approach or organisation is giving holistic healthcare.
Measuring the degree of holism underlying
a professional or organisational approach
requires a comparison between the particu-
This failure by such powerful organisations
to specify the theoretical basis underlying
their decisions is in stark contrast to the research community where the importance of
specifying the theoretical underpinning of
complex interventions (such as healthcare
provision) has been stressed [14].
It is important because there are in fact very
many models of illness. Some have been
articulated and written down, but most are
implicit and not formally described. Some
are rather more logical and comprehensive
than others.
In the absence of any acknowledged basis
for the important political and practical decisions made by large healthcare management organisations, one must assume that
the people responsible for decisions simply
use the current, culturally dominant model.
Current model of illness
Therefore we now need to review the assumptions made by most people concerning
illness, so that we can deduce the model
underlying most healthcare decisions both
at the level of organisations and at the level
of individual clinical decisions.
Holistic health care. Derick Wade.
November 25th 2009.
The first and perhaps most fundamental assumption made by most people is that all
illness in an individual can be traced back to
some specific, usually single disorder of a
part of the body of the patient. This is
termed the disease; it refers to some distinct
abnormality in structure and/or function of
a single organ or organ-system. It is also
known as the pathology. The disorder is assumed to be within the body.
Thus, for example, observed weakness of
arm movement could be attributed to a
stroke (an area of cerebral infraction in the
brain itself caused by a bleed from an artery). The patient would be described as
having “had a stroke”. Another term applied is the diagnosis – the patient has a diagnosis of stroke. This is a confusing word
because the term diagnosis also applies to the
process of discerning (diagnosing) the underlying disease.
A second assumption, almost as strong, is
that all symptoms are due to disease, to a
disorder within the body. This is particularly so because the very term symptom implies that the experience is symptomatic of
something. If one believes that all illness is
due to disease then it is natural to attribute
symptoms to disease and if all disease is attributed to dysfunction of part of the body,
then symptoms will be attributed to dysfunction of part of the body.
Thus, for example, if someone suddenly has
difficulty in moving an arm, and notices that
their speech is slurred and that their hand
feels odd when touched, these would be referred to as the symptoms of stroke (or whatever the underlying pathology is).
A third, less strong assumption is that all
disease causes symptoms. It is generally accepted that symptoms can sometimes arise
late in the course of disease. Indeed this
underlies the practice of screening for diseases such as diabetes, hypertension and
carcinoma of the breast.
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A further less well articulated assumption is
that people have two parts to their existence
– the ‘physical’ and the ‘mental’ – and that
these aspects of a person are separate and
unrelated [12]. This is a common belief [15],
most obviously demonstrated in the almost
universal separation between ‘mental’
health services and ‘physical’ health services.
This assumed separation is a form of Cartesian Dualism where a person’s body and
consciousness are considered as two separate entities; the problems that follow from
this assumption practically [16] and philosophically [17] are covered elsewhere.
More importantly, although it is less openly
acknowledged, most people and many organisations are generally more sympathetic
towards people with so-called ‘physical’ (or
organic) disease than they are towards people with ‘mental’ or ‘psychological’ illness.
This can cause problems.
There are some other more general, social
assumptions about illness that were first articulated by Parsons in 1951 [18]. The first
of these is that disease within the body is
caused externally; the person who is ill is
assumed to be the passive victim of the disorder and not responsible for his or her illness.
This leads on by implication to a second set
of commonly held assumptions, namely that
treatments are an external intervention that
will (hopefully) cure the disease, and that
the patient is a passive recipient of treatment with only a minor role to play if any.
Parsons also pointed out that being sick (i.e.
being in the sick role) relieved the patient of
many social responsibilities such as work,
childcare etc until the person recovered.
At the same time he also emphasised that
the patient had two concomitant responsibilities (which are now often overlooked).
The first was to seek expert help for the ill-
Holistic health care. Derick Wade.
November 25th 2009.
ness from appropriate professionals, and to
take any treatments or follow any advice
suggested. The second was to strive to return to full social functioning as quickly as
possible.
The biomedical model of illness (figure 1)
These assumptions form the basis of the current dominant model of illness. This is best
termed the biomedical model [19], sometimes referred to disparagingly as “the medical model”.
It is in fact difficult to find an agreed definition or description of the biomedical model
this model [13]. It arises from the scientific
method of investigation which simplifies
and reduces complexity, looking for direct
cause and effect relationships. The biomedical model assumes linear unidirectional relationships and does not directly acknowledge complexity (non-linear
or bi-directional relationships).
The biomedical model of illness fails to predict or explain some important observations. Some examples will be given, but
there are many others.
It is now recognised that at least 20% or
more of all people attending any hospital
clinic do not have a specific disease that can
account for their symptoms [20][21][22].
Furthermore 5%-10% of inpatient beds may
be occupied by such patients [23].
There is no fully agreed word or label for
this type of illness. The term used in this
paper will be functional illness (or functional problems) but other current terms include medically unexplained symptoms,
somatisation and non-organic disorders.
This group of disorders includes such ‘diagnoses’ as fibromyalgia, chronic regional pain
syndrome, chronic low back pain, migraine
and headache, irritable bowel syndrome,
ME syndrome and chronic fatigue syndrome. The biomedical model of illness
cannot explain these illnesses at all.
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It is well established that non-medical factors determine retirement on grounds of ill
health, despite the fact that it is a medically
validated process. A doctor certifies that the
claimant has a specific illness and that the
illness precludes paid employment. For example in four of five UK organisations surveyed, the modal time of retirement on
health grounds coincided with the time
when an enhanced disability pension became available [24]. In a Finnish study, the
rate of retirement on health grounds doubled in organisations which experienced
major downsizing [25]. These unsurprising
observations are not consistent with the
simple biomedical model of illness.
Thirdly it cannot explain why the rate of invalidity (as indicated by medically confirmed sickness benefit claims) is increasing
while at the same time the success of medical diagnosis and treatment is improving.
Last the biomedical model fails in terms of
commissioning (purchasing) because in
most systems the payment relates to the
given diagnosis. This does not take into account such matters as the process of making
a diagnosis, the effects of associated or unrelated diseases, the effects of ‘social’ factors
and the effects of disease severity.
For example someone who has had a stroke
might have a small lacunar cerebral infarct
and recover more-or-less full independence
within a few days with minimal need for
any intervention. In contrast a person with
an equally small volume of cerebral damage
leaving them in the ‘locked-in’ state requiring major support and rehabilitation and
huge changes in housing etc will require
many months of rehabilitation in hospital.
Attempts have been made to adjust the current payment systems, but none have been
very successful.
Holistic health care. Derick Wade.
November 25th 2009.
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Figure one
The biomedical
model of illness
•
•
Organ
Pathology
Disease, disease label
•
•
Body
Impairment
Symptoms & signs
•
•
Functions
Dependence
Disability
•
•
Social
Roles, status
Handicap
The fundamental, underlying
cause or initial dysfunction, or
damage is within the body at
this level.
Physical environment
(moderates effects of impairments)
• Housing
• Equipment
• Adaptations
Holistic health care. Derick Wade.
November 25th 2009.
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The assumptions underlying the biomedical
model of illness are also invalid.
usually be worse even to the extent of recurrence or maintenance of the disease.
First, ‘symptoms’ are extremely common.
Studies have shown that most people have
experiences that could be termed symptoms
on a daily basis [26][27], and indeed may
have about two ‘life-threatening’ symptoms
in a six-week period without actually ever
being sick or attending a doctor [28].
Fifth, it is common experience that mood
affects performance. Indeed whole management lectures and courses are based on
the premise that altering motivation and engagement improves performance.
Thus, far from being rare events indicative
of an underlying disorder within the body,
symptoms are something that we all experience on a daily basis; most of the time we
recognise that they are in fact within normal
experience.
Second, much pathology (disease) is asymptomatic. For example about 10% of people
aged 65 years or more have areas of cerebral
infarction (stroke) on scanning, yet have
never had any symptoms from it [29].
Screening programmes detect so-called abnormalities that are not only asymptomatic
but probably would never be symptomatic.
For example there is considerable debate
around the cancers detected in breast [30]
and prostate [31] screening programmes.
Next it is demonstrably untrue that patients
are always ‘passive victims’ because so
much disease is related closely to patient
behaviour. For example, smoking causes
many diseases; alcohol causes many diseases; obesity causes many diseases; practising unsafe sex may lead to HIV infection.
These examples alone show that a proportion of diseases are caused, ultimately, by
the patient him- or herself.
Further, even with surgery and drug treatments the patient has to be an active partner
for treatment to succeed. At its most basic,
if you do not take your tablets, you cannot
benefit from them. More importantly, if a
patient does not alter his or her lifestyle by
exercising more, participating in rehabilitation, losing weight etc then the outcome will
Last, and perhaps most importantly, the
biomedical model of illness perpetuates a
faulty logic in analysing and understanding
illness. Specifically the assumption that all
illness can be attributed to disease which
affects only a part of the whole body prevents any exploration of an alternative explanation, namely that illness arises from a
problem at the level of the whole person
within their situation.
This logical failure is sometimes known as
mereological fallacy, and a similar logical
failure has been explored in relation to consciousness [17]. Mereology is concerned
with studying and analysing the relationships between the parts of a system and the
whole system, and whether a phenomenon
belongs to a part of the system or to the
whole system.
In relation to illness, the biomedical model
assumes that there must always be a disorder of a part of the whole. It does not consider that the whole person may be ill without any specific part of the person being abnormal.
This logical fallacy has serious consequences
in relation to functional illness (i.e. the 20%
of people who have problems without underlying disease). Clinically it impels doctors to continue investigation for a disorder
within the body. This may cause significant
harm: all investigations carry risk, and the
process may prolong and reinforce the illness behaviour.
In research it leads to a fruitless hunt for
specific causes such as toxins and viruses; it
Holistic health care. Derick Wade.
November 25th 2009.
is likely that any abnormalities identified
will be secondary phenomena anyway.
And in healthcare management terms, there
is no diagnostic or payment code for functional illness. Consequently the existence of
functional illness is not recognised by commissioning organisations who nonetheless
pay large sums for these patients.
In summary, I have suggested that most
modern healthcare is based on a biomedical
model of illness. The biomedical model has
been a spectacularly successful model for
about 150 years, so much so that it is not
overtly described at all. It has allowed the
identification, classification and rational
treatment of a huge number of diseases –
the International Classification of Disease
issue 10 (ICD-10) is the culmination of the
process [32].
Nonetheless there are many ways in which
it is no longer an adequate model of illness;
it is reductionist and fails to recognise the
multi-factorial and mathematically complex
nature of most illness. A better model of illness is now needed.
Biopsychosocial models of illness.
The need for a better model of illness was
recognised at least 30 years ago when
George Engel challenged healthcare practitioners about their use of the biomedical
model. He suggested moving towards the
biopsychosocial approach, so named because it recognised the importance of biological factors, psychological factors and social factors [33]. He also introduced the idea
that General Systems Theory should be applied to illness.
Other authors have also emphasised the
complex nature of illness, the utility of a biopsychosocial approach and the use of systems theory [34][35]. However, other than
emphasising the need to consider biological,
psychological and social factors, these authors have not developed a specific model.
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At about the same time, in 1980, the World
Health Organisation (WHO) published its
first classification of the consequences of
disease [36]. This did use the biopsychosocial approach to illness and theories of sociologists such as Nagi [37] to develop the
classification which used three different levels or domains to encompass all the consequences of disease:
• Impairments – alteration in physiological functions of or within the body
• Disabilities – alteration in bodily functions
• Handicaps – alteration in social functioning
One specific feature of this first WHO classification should be noted: it completely ignored the importance of context and the environment.
The terms disability and handicap were
considered stigmatising by some people, not
unreasonably. Between 1980 and 2001 the
WHO expanded and improved its classification, aided greatly by people with disabilities, and it finally published the International Classification of Functioning (WHO
ICF) in 2001 [38].
This revision included significant advances
both in terminology and in the underlying
concepts. The word disability was replaced
by (limitation in) activities; this was not only
less stigmatising but also emphasised that
the core concept was of change in goaldirected behaviours. The word handicap
was replaced by (change in) participation in
social life; this was also less stigmatising
and importantly emphasised that the core
concept was of a change in social position.
More importantly the WHO ICF (2001) acknowledged that contextual factors might
moderate the effects of disease, and suggested two domains (physical and social).
However it must be noted that the WHO
ICF remains a classification of the conse-
Holistic health care. Derick Wade.
November 25th 2009.
quences of disease. This implies a continued dependence upon the biomedical model
of illness. The classification itself is probably unworkable in practice – despite enthusiastic advocates [39][40].
There is one particular failure in its classification; it does not include any consideration
of quality of life or well-being. This failure
is understandable because the concept of
quality of life is difficult to define, and impossible to categorise or measure accurately.
Nonetheless well-being is a vital domain of
each person’s life that should be included in
any holistic model of illness.
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In summary the biopsychosocial model of
illness seems to be a significant advance
upon the biomedical model of illness. It has
been used as the basis of a system for classification of various aspects of illness, and the
implied model of illness underlying the
classification has been used as a basis for
research and policy for many years and has
been useful, for example in national guidelines on acquired brain injury [41], multiple
sclerosis [42] and stroke [43]. It could be a
good basis for a holistic model.
Brief overview so far
So far we have established that:
• Models of illness are used to analyse how illness arises and to predict what
treatment might be effective; most models are implicit and not formally described.
• The biomedical model, which primarily assumes that all illness arises from
within the body and is caused by an initial dysfunction of a part of the body, is
the current dominant model of illness.
• The biomedical model of illness has several weaknesses:
o The underlying assumptions are all invalid.
o It is not successful at explaining some illnesses, especially the group of
‘functional illnesses’.
o It is not successful when designing health care systems.
• The biopsychosocial model of illness is an alternative model that:
o Acknowledges the importance of factors other than disease.
o Suggests a systems approach to illness.
o Has been used as the basis for an international classification system.
• A holistic model should:
o encompass all factors that relate to illness in some way.
o explain or predict all illnesses, especially functional illness.
o improve the organisation and commissioning of healthcare.
o improve clinical management of individual patients through allowing a
better analysis and understanding of the whole situation.
Holistic health care. Derick Wade.
November 25th 2009.
A holistic model of illness
I am now going to present a holistic model
of illness that is based on and derived from
the WHO ICF classification of the consequences of disease. I will refer to this as an
expanded WHO ICF model of illness.
Throughout the description I will simply
refer to the person, because the model
should encompass and be applicable to all
people, whether or not they are ill at the
time. The model is illustrated in figure two.
Four person-centred systems
The model first suggests that there are four
levels or systems centred on the person that
are relevant to illness. It should be noted
that each level can, in principle at least, be
subdivided into two perspectives: that of the
person and that of external observers. More
importantly it must be emphasised that it is
not necessary for there to be any abnormality at any particular level when someone is
ill. Specifically disease is not the cause of all
illness.
The first system to be considered is that of
an organ or organ system within the body
of a person. Alterations in the structure or
functioning of an organ (as a subsystem of
the body) are referred to as pathology, with
disease being the common synonym. The
personal aspect of this is the disease label
applied to or used by the person concerned.
This system is itself further divided into systems such as cells, genes, and chemical
pathways, and these systems are currently
the main focus of most biomedical attention,
both clinically and in terms of research.
However when considering the phenomenon of illness as a whole, it is not necessary
to be concerned with these lower levels.
The next system is that of the whole person
(to include both bodily and mental domains); it is the overall functioning of all the
different organs and organ systems present
within a body.
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Alterations in the structure or function of
the person as a whole are referred to as impairments, and the common synonym is
symptoms (and, medically at least, signs).
Several important aspects of impairment
must be emphasised. Many impairments
such as pain, altered sensation and double
vision are personally experienced and they
can only be known about because the person tells someone. These impairments cannot be externally verified.
Second, many impairments described as
signs are no more than externally derived
constructs; in other words they are a method
of summarising a series of observations into
a single word. For example a neurologist
will analyse a person’s speech and state that
they have aphasia, an impairment of the use
of language, but this is not otherwise verifiable. The presence of aphasia is simply a
deduction based first on observing communication and second on using a model of
how speech and communication occurs in
order to determine the abnormality.
The power of constructs is that they are
generally very useful; the danger is that they
may be considered as ‘objective’ or concrete
phenomena that can only have one explanation. We have demonstrated that ‘upper
motor neuron weakness and spasticity’ can
arise without any disruption of the nervous
system [44].
Third, the common synonym for impairment, symptom, itself implies that there is
always an underlying cause, specifically an
underlying disease, but this is not necessarily true.
Holistic health care. Derick Wade.
Level / system
Name in model
• External synonyms
• Person’s perspective
Organ
Pathology
• Disease, diagnosis
• Disease label
November 25th 2009.
Figure two
The holistic
model of illness
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Context
Location
• Components
The person
Personal context
Person’s own:
• Attitudes, expectations
• Beliefs, self-efficacy etc
Person
Impairment
• Symptoms & signs
• Experiences
Temporal context
Person’s:
• Stage in life
• Stage in illness
• Routine / structure
Choice / free-will
Person in physical context
Activities
• Behaviour, disability
• Perceived quality of activity
Physical context
Environment, objects, carers:
• Peri-personal & home
• Community
Person in social context
Participation
• Roles, social position
• Quality of role performance
Social context
External
• Attitudes, expectations etc
• Laws, responsibilities
All levels
contribute
Well-being
Quality of life
• Personal evaluation
Holistic health care. Derick Wade.
November 25th 2009.
Thus another way to consider this level is to
refer to the experiences that the person has
(such as pain, or altered sensation, or fatigue, or difficulty in moving a limb and so
on) and/or to describe both the observations
made and the deduction made. There is
otherwise a real risk that the impairments
will be ‘objectified’, being made concrete by
being named when in fact they are no more
than reported personal experiences or implications derived externally on the basis of
observed behaviour.
These first two systems – the individual organs within the body and the whole person
- refer to the person alone. The next system
to consider is the person’s interaction with
the physical (observable) environment. This
consists of the person’s activities, the behaviours that they undertake usually to achieve
various goals. The goals may vary from the
immediate (satisfying thirst) to the longterm and abstract (becoming a grandfather,
or head of a department). Alterations at this
level are still usually referred to as disabilities, although the WHO ICF refers to them
as limitations on activities.
Three important points must be made about
this level. First, it encompasses externally
observable actions; a person’s interaction
with the environment is open for all to observe, and can be recorded (for example) on
video.
Secondly, there is also a personal perspective on the performance of activities. Although observers can both measure and describe the activity, only the person can rate
their own perception of their performance of
the activity. For example a therapist might
describe gait as being ‘slightly slow with a
minor limp’ but to the person concerned the
visible limp might be of major importance,
for example because it shows to others that
the person has a problem they do not want
to disclose. Alternatively they may be unconcerned about a limp or even appreciate it
as it discloses that they have a problem;
Page 13
many patients with cognitive losses after
head injury are very upset because their
“hidden disability” is not recognised or acknowledged.
Last, this system is the one that depends almost entirely upon a person’s goals. Behaviour is goal directed, and disability can only
be understood with reference to a person’s
goals.
The fourth and final level is the most abstract, and is best considered as the person’s
interaction with the social environment. It
refers to the roles that they play.
A role is determined not only by the person
(as actor) but also by others (as audience).
Roles, and social position depend in part
upon a person’s ability to undertake certain
activities but they are also determined by
many other factors. Roles are extremely difficult to observe ‘objectively’ because they
depend entirely upon the perceptions of
those involved, both the person and others.
Most roles need to be agreed mutually.
These four levels are concerned primarily
with the person. It is worth restating that
only activities are externally observable.
Impairments are deduced from observations
of behaviour and/or report from the person.
Disease is initially diagnosed on the basis of
a characteristic pattern of abnormalities
sometimes confirmed by direct observation
of the organ (e.g. by biopsy). Social participation and roles are also indirectly inferred
from observed behaviour.
Four contextual factors
The model then recognises four factors that
may moderate the interactions between the
four systems; these contextual factors may
themselves also cause alterations directly in
any of the four person-centred systems.
Holistic health care. Derick Wade.
November 25th 2009.
The contexts are:
• Physical; the observable environment
• Social; the local cultural environment
• Personal; the sum of a person’s experiences and personality
• Temporal; both the stage a person is
within the illness and the stage the person is at within their life.
The physical context is the most obvious,
and the easiest to understand. It refers to all
objects and structures that a person may use
or be affected by. Obviously it includes the
structure of the house and built environment but it may also include adaptations
made to the environment such as adapted
cutlery, clothing adaptations, rails etc. Further it will include any specific equipment
provided such as walking aids, prostheses,
and orthoses.
Less obviously it is important also to include
other people as providers of hands-on
(“physical”) care as part of the physical context. This does not mean that one can ignore
the separate but vital role of other people as
social contacts. However it is clearly important in a practical sense to consider how
hands-on help with dressing, feeding or
cooking will be delivered, and in some circumstances it could be from someone living
in the accommodation with no family or
other emotional relationship at all with the
ill person (e.g. a lodger might prepare and
leave a breakfast before going to work.).
This understanding that carers will usually
provide both ‘physical’ and ‘social’ input
may alert one to a common practical problem. Many younger people who are dependent upon carers on account of a head
injury, or multiple sclerosis or cerebral palsy
may also consider these carers as friends.
This is unsurprising because often the carers
are the major or only social contact a severely disabled person has. Unless there is
formal recognition of the distinction between the role of carers in providing necessary ‘physical’ help and the incidental but
Page 14
inevitable social interaction and relationships that develop, practical problems can
arise in the delivery of care.
The social context needs careful consideration. It primarily refers to the particular
people in contact with or of importance to
the person, and it concerns the attitudes and
expectations of those people. However it
also includes the broader aspects of culture
as evidenced by people met incidentally in
the community, officials and bureaucracy,
and applicable laws and other rights and
responsibilities proscribed in some way.
The importance of social context in determining illness has been demonstrated in at
least one study [45][46]. The social context
may also explain the observations made
concerning disability pensions [24][25].
The personal context is less obvious but
possibly the most important. It encompasses the person’s ‘personality’ and general
coping skills (themselves derived from both
genetic factors and past experiences), the
person’s own expectations, attitudes and
goals, and also the person’s specific experiences of the illness that they have and of
other illnesses and events. For example a
history of reported childhood abuse is associated with functional illness [47].
It could be argued that the personal context
is part of the ‘body system’ or ‘impairment’
level, but the difference is that impairments
refer to experiences and changes whereas
the personal context refers to a response set,
the factors that influence how a person responds and adapts to a particular circumstance and what goals they have.
The last contextual factor is time, and there
are three aspects to the temporal context.
The first is the person’s stage of life. This
primarily concerns their age and the expectations associated with that age. It also affects both the resources available to them at
Holistic health care. Derick Wade.
November 25th 2009.
their stage of life, and the responsibilities
that they have (e.g. caring for children).
The second is the person’s stage of their illness. A person’s concerns when they have
only just become ill will be different from
their concerns four years after disease onset.
And people acquiring their illness at birth or
in early childhood will have yet different
concerns and expectations.
The last, important aspect of the temporal
context is specifically important in rehabilitation, and it concerns the structuring of
time. Throughout life most people have a
routine which is largely imposed externally.
This routine affects the day, the week, the
year and longer periods. Although there is
obviously variation and choice, nonetheless
most people have a highly structured life
pattern.
In contrast many people with illness, especially long-term illness lose all routine.
They may go to sleep at any time, get up at
any time, and have very little to do in the
day. The effects of a lack of temporal structure have not been well researched but may
explain the increased rate of illness and
mortality seen shortly after retirement from
work and the low mood and low level of
well-being of many people with long-term
illness.
Two other factors: choice and well-being
There are two other major factors that need
to be included in any comprehensive model
of illness: the person’s free-will, their ability
to make choices; and the person’s judgement on their own level of well being or
quality of life.
Choice is important. It is generally agreed
that all people can make choices and are responsible for their behaviour; this is the basis of the criminal justice system. Yet much
healthcare seems to forget that people attending healthcare will make choices.
Page 15
Choice is particularly important in longterm illness because healthcare professionals
are rarely able to give any firm evidencebased advice or treatment knowing the
long-term consequences. Patient involvement in all choices about treatments should
be the normal expectation. Furthermore
even if the choice is not to follow the “best
advice” given, the choice should be respected not least because we can rarely actually know whether our advice was necessarily correct or best!
At the same time we should also recognise
that explicitly acting to alter a person’s
choice is quite legitimate, provided it is
done openly and without deceit or by immoral means. For example if someone with
a head injury is screaming to gain attention,
we may choose to ignore it but to respond
when he is quiet, so that he chooses not to
scream. More generally people are now receiving direct incentives to improve their
health in some situations [48].
It is also quite legitimate to face the person
with the consequences of their choice. For
example if someone with poor balance
chooses not to use a rollator when walking,
they should be informed of the risks and of
any actions that could reduce that risk.
Quality of life is another concept that is important, but difficult to define or measure.
It is ultimately a judgement made by the
person about their situation. It is probably
influenced by many factors, including personal preferences. It is also likely that quality of life often renormalizes over time in
chronic illness.
What is illness?
The next step is to discuss the nature and
aetiology of illness using this model. The
main contention is that illness is a social
state usually initiated by the person and
confirmed by others.
Holistic health care. Derick Wade.
November 25th 2009.
The central characteristic of illness is that
the person will consider themselves ‘sick’
(i.e. ill); they will also generally enter “the
sick role”, generating behaviours indicative
of this such as attending doctors or other
healthcare professionals (including, now,
alternative healthcare practitioners). The
person will also often absolve themselves of
some responsibilities by limiting other behaviours. It should be noted that entering
the sick role fully requires at least one other
person to accept that the person is ill.
The presence of disease does not inevitably
cause someone to be ill. One may have a
‘silent’ pathology (e.g. an ovarian tumour
with no symptoms), or one may have experiences such as odd episodes of tingling
that are attributed (by the person and/or
others) to normality while in fact they may
be related to early multiple sclerosis.
It is also possible for a person to be considered ill by others but not to consider himself
ill. The most obvious example is a person
with delusional mental illness, or psychosis
where the behaviour is dangerous to the
person or others but the person has no insight into the unusual nature of their experience and behaviour and does not agree that
they are ill. Less commonly, people who
simply behave in socially unusual ways, for
example choosing to live in squalor rather
than tidying their house are considered ill
by others and referred to healthcare for diagnosis and treatment.
More importantly, this analysis suggests
that it is quite possible to be ill without disease. The central feature of illness is that the
person acts in a way that indicates a belief
that he or she may be ill. Leaving aside deliberate pretence (e.g. malingering), this
simply requires that the ill person thinks
that they have or may have something
wrong with their health. In the current culture, this translates into a belief that they
have a disease or disorder within the body.
Page 16
In the current culture, most other people
will take a similar view if presented with the
same experiences. Thus if a person presents
themselves as ill, and this presentation is
accepted by others, especially but not necessarily by healthcare professionals, then they
indeed will have an illness.
Therefore illness is best described as a range
of behaviours that are understood by others
to indicate that the person considers him- or
herself to be ill. Occasionally, but not always correctly, a person’s behaviours may
be considered by others to indicate that the
person is ill despite not seeking help.
In other words illness is a socially constructed state within the system, being
based upon the behaviour of the person.
Becoming ill
If this definition is accepted, then the next
question is how or why does someone consider herself ill and behave in that way; just
as interesting is why others, especially
healthcare professionals consider that person to be ill and thus validate the illness.
There are four steps to achieving illness.
The first step is that someone notices a
change in himself. The alteration may be
the occurrence of new ‘symptoms’ or it may
be a change in existing ‘symptoms’, or it
may be a change in the ability to perform
activities or fulfil roles. It is a change in experience.
For example a person may experience pain
in the knee without necessarily any alteration in walking or a person may experience
a change in walking, such as a limp without
any symptoms. In practice either could
arise from the same underlying pathology,
osteoarthritis of the knee.
The next step is for the affected person to
consider that this change is not simply expected (in the situation), but represents the
Holistic health care. Derick Wade.
November 25th 2009.
effect of some other underlying disorder.
The nature of this disorder will be determined by the model of illness used by the
person. Given that most people use a biomedical model, most people attribute
change to a disorder within the body (a disease).
For example the person with a limp would
not be concerned if he had sat on a hard seat
and developed a ‘dead leg’ (due to pressure
on the sciatic nerve). However, if the person
could not think of an alternative benign explanation, he might consider the limp to be
caused by some underlying disorder. The
specific attribution (of causation) is clearly
subject to many influences such as expectation in relation to a specific change. For example, some people worry that any limp
might represent motor neuron disease, perhaps because a relative presented with that
disease in that way.
The third step is for the person to consider
that the possible cause is within the remit of
the healthcare system. This is also a cultural
phenomenon and depends upon the dominant model of illness within the society.
The last step is for at least one other person
to agree that the person has a change that is
or may be due to an underlying condition
that is accepted as causing someone to be ill
(rather than ‘bad’, or unlucky or simply not
ill). Full validation usually depends upon a
person within the healthcare system, not
necessarily a doctor. Indeed many people
now have illnesses ‘diagnosed’ by a variety
of practitioners where the diagnosis is not
accepted by many doctors (e.g. chiropractic
diagnoses).
Functional illness
This analysis offers an explanation of functional illness. In brief the hypothesis suggests that illness arises as part of a person’s
adaptation to changes within the whole system. Many illnesses arise when an organ is
diseased; as the disorder progresses there
Page 17
comes a point when the body cannot adapt,
and symptoms arise. This is the traditional
understanding of illness.
However it is also plausible that increasing
demands upon a person from other factors
may equally lead to symptoms. Indeed few
people will cope with excessive demands
without developing symptoms. If the demands are obvious (to others) and evidently
(to others) excessive, then most people will
both admit to the symptoms and will acknowledge the cause.
However it is also plausible and in fact inevitable that some people are less able than
others to adapt to demands that lie within
the normal range. Moreover some demands
are self-imposed. Under these circumstances the person is just as likely to experience symptoms but is much less likely to
attribute them to external or self-imposed
demands. Instead the symptoms or other
problems will be attributed to internal disease.
This attributional bias towards ‘organic’, internal disease rather than acknowledging
the relevance of other factors arises for cultural reasons. Culturally it is not acceptable
to admit that one cannot cope with a situation unless the situation is exceptional. Culturally it is usual to attribute symptoms to
disease. Furthermore the prevailing culture
in healthcare (exacerbated by a legal framework) means that specialist hospital doctors
are unrealistically afraid of failing to diagnose disease even when it is obvious that
the person must have a functional disorder.
Consequently neither the person who feels
unwell, nor his friends and family, nor his
medical advisors will consider the role of
contextual factors, at least in the early
phases of illness. By the time that it is obvious that there is no underlying disease it
may be too late to alter and reverse the beliefs of the person who is ill.
Holistic health care. Derick Wade.
November 25th 2009.
Page 18
Summary of holistic model
In summary the expanded WHO ICF model of illness:
• Recognises four major systems concerning the person
o The organs within the body
o The body as a whole, generating experiences and skills
o The body’s (person’s) interaction with the physical environment, generating
goal-directed activities
o The person’s interaction with the social environment, generating social roles
and social participation
• Suggests that four major contextual factors can affect the person’s interactions and
experiences:
o The physical context
o The social context
o The personal context
o The temporal context
• Identifies two major factors difficult to locate elsewhere:
o Choice or free-will
o Well-being, or quality of life
• Suggests that illness is a socially determined state requiring four steps:
o An experience that is outside normal
o Without any obvious (external) cause
o Attributed to an internal cause within the remit of healthcare
o Accepted by others as being the situation
• Predicts that illness will arise when
o The external or internal demands upon or changes within a person
o Exceed the capacity of that person to respond or adapt to the changes or demands
o Leading to symptoms/experiences that are attributed to disease
Holistic health care. Derick Wade.
November 25th 2009.
Is the holistic model valid?
The last section of this paper developed a
holistic model of illness largely without reference to evidence. It is now time to consider the evidence behind this model.
Ultimately theoretical models cannot be
proved. They can only be disproved. Evidence showing that the simple biomedical
model of illness is invalid has already been
given. Thus a new model is certainly
needed, and this is one. Models can however be validated or strengthened in several
ways such as being consistent with and able
to explain existing observations.
This model can easily explain observations
such as the influence of social context upon
rates of disability pensions [24][25]. Furthermore there is experimental evidence
that altering social (cultural) context can alter rates of invalidity [46]. This model is
consistent with and able to accommodate
current observations.
The biopsychosocial model is considerably
strengthened by it success in predicting experimental findings. A biopsychosocial
model was used explicitly in the development a measure of clinical case complexity
for use in healthcare. This measure was the
INTERMED [49][50][51] and a series of studies have confirmed experimentally findings
that would be predicted by the holistic
model.
For example the measure can identify people with back pain who are unlikely to return to work [52], and people on renal dialysis with a lower quality of life [53], and people with lung disease who use more healthcare resources [54], and people with multiple sclerosis who needed more complex
healthcare input [55]. The INTERMED
seems to encompass a single construct of
biopsychosocial complexity [56]. And using
this measure also may help identify people
who benefit from additional multidisciplinary care [57][58].
Page 19
A related, powerful piece of supporting evidence is that this model would predict the
occurrence of functional illness. Although
the model cannot predict the expected frequency of functional disorders, a systems
approach to illness would predict that a person might become ill without having any
specific underlying disorder. This occurs.
The model’s analysis of functional illness is
supported by several pieces of evidence.
Interventions to alter cognitions and behaviours (cognitive behavioural therapy) improve functional illness [59][60]. Functional
illness can be diagnosed by analysing the
actual language used by people with a functional disorder [61][62]. And the variable
nature of symptoms [63] is only consistent
with a multi-factorial aetiology.
The model put forward here is also supported because it has been found practically
useful. The original WHO ICF classification
model is now widely used in rehabilitation
(not the classification itself, but the ideas of
impairment, activities, participation and
context). The expanded model has been
used successfully to structure large complex
guidelines such as the NICE National guideline on multiple sclerosis [42] and the National Clinical guideline for stroke [43].
Finally the model is very useful in understanding many other phenomena and in
suggesting some solutions. The table at the
end shows some general lessons that can be
derived from using the model. There is a
considerable body of evidence that supports
the validity and the utility of this model. I
am unaware of any evidence that proves
this model to be flawed.
The healthcare system (figure three)
Finally, before discussing how holistic
healthcare can be carried out and how it
might benefit patients and healthcare systems, it is important to analyse the healthcare system itself, briefly.
Holistic health care. Derick Wade.
November 25th 2009.
Page 20
Figure three
The health
care process
l
Patient presents:
• Self
• By others
Return to start of cycle
Data collection
(diagnosis, assessment)
• Identify problem(s)
• Establish cause(s)
• Suggest prognosis/treatment
Formulate situation
• Specify problems
• Interacting causes
and relevant factors
Evaluate – against goals:
• Not achieved, not achievable
• Not achieved, new goals
• Not achieved, needs more expertise
• Achieved but new goal(s)
• Achieved, no new goals
Interventions / actions
• Support - maintain
• Treatment – alter outcome
• Data collection
Transfer care to:
• More specialist service
• Less specialist service
• Community service
• Person - self management
Set goals
• Long and short-term
• Centred on person
Organise actions
• Within team/organisation
• Outside team/organisation
• Correct order and timing
Holistic health care. Derick Wade.
November 25th 2009.
Healthcare is best considered as a problemsolving process, with different parts of the
healthcare system focusing on different aspects of illness and sometimes, possibly,
having different goals. However all healthcare processes will have the following general structure. The amount of effort devoted
to each stage will vary according to the
situation and setting.
The first step is for the patient to present to
the healthcare system. Usually this will be
initiated by the person. In two circumstances this is not the case. If the person
falls ill suddenly and loses the power or
ability to seek help, others may need to do
initiate healthcare involvement.
Second, if the person’s illness is such that
they are unaware of their abnormal state, for
emotional, cognitive or delusional reasons
then someone else may initiate contact. It
must also be recognised that others may
sometimes refer a person who has no illness
to the healthcare system simply because
they do not like or understand their behaviour or choices.
The second step is for the healthcare system
to collect information to establish:
• That there is indeed any problem present that is appropriate to healthcare
• What other health problems exist
• Information needed to identify the
cause(s) of the situation
• Information needed to identify the best
treatment(s)
In medical settings this process is known as
making the diagnosis; in rehabilitation settings it is often referred to as the assessment
process. In either case the goal is to understand what is wrong, why the problem has
arisen, and what can be done to alleviate the
situation.
The next, third step is to use the data collected formulate the case, specifying the nature and extent of the problem(s) and the
Page 21
causes and factors relevant to management
and resolution of the problem. In practice
these two steps (data collection, and formulation of the situation) occur in tandem, and
experienced professionals collect data to
confirm or refute initial hypotheses.
The fourth step is to use the information to
set management goals. The potential goals
fall into one or more of the following three
categories:
• Providing support.
Support is defined as interventions
needed to maintain life, safety and wellbeing. In some situations support may
be long-term (e.g. someone who needs
long-term ventilation or someone who
needs long-term nursing care). In principle support does not lead to sustained
change; as soon as it is withdrawn the
situation deteriorates.
• Undertaking treatments.
Treatments are defined as interventions
that are intended to alter the natural history of a condition. In principle treatments are limited in time and one expects the achieved change to be maintained upon withdrawal of the intervention.
• Collecting more data.
This may be needed to improve the
analysis and understanding of the situation.
Goal setting is rarely done explicitly in acute
settings, but it is certainly implied. However it is vital in rehabilitation where it is
usual to set long-, medium, and short-term
goals both to help motivate and engage the
patient and to help structure and organise
the many actions needed.
Thus, in complex cases at least, an important
component of the fourth step is to organise
the many actions needed. This may require
collaboration between many different people, professions and organisations.
Holistic health care. Derick Wade.
November 25th 2009.
The next step is for the planned actions to
occur. These actions, especially treatments
are often considered the main part of the
health care process. Indeed in ‘item of service’ payment systems, the payment is generated by the specific treatment even if there
are many preceding actions, concurrent actions and subsequent actions. This is fair
only in the rare situations where variation
around the pathway leading up to and following on after the treatment event (usually
an operation) is small.
In the sixth step the situation is re-evaluated
to determine whether:
• treatment goals have been met
• further problems needing more action
have been identified
• any problems remain needing treatment
• longer term support needs, if any, have
been identified and plans made to meet
these needs
If unresolved problems remain, the cycle
reiterates.
The seventh and final step, if no further
problems remain to be resolved by the particular part of the healthcare system, is for
the patient’s care to be transferred away
from that system.
The options are to transfer care to:
• a more specialised service, if problems
remain which could be resolved given
more specialised input
• a less specialised secondary care system
• primary care (community care)
• the patient and family (selfmanagement)
The final disposition should be to self-care.
Some people may have no further healthcare problems, but most people with longterm problems will need instruction on how
best to manage their condition, and on when
and how to make contact with specialist
services, and they will usually need advice
on life style.
Page 22
Improving patient care
It is now possible to consider how the holistic model of illness might improve patient
care both directly, and through improving
the healthcare system.
Patients who have a single disease that can
be treated will generally be well-served by a
healthcare system based on a biomedical
model of illness.
However many people now have complex
health problems:
• they have multiple pathologies, often
in different systems
• the diseases are often not cured, and
may need long-term specific management
• the patient has multiple impairments
that interact with each other
• many patients have significant limitations in many activities such that they
need support on a daily basis
• many patients have very limited social roles, and ‘being a patient’ may
constitute and important role
• the patient’s beliefs and expectations
may be quite different from those of
the healthcare team
• the social and physical context is often unsuited to people with a longterm and disabling condition
This complexity has several consequences.
It is difficult for a service focused on a single
disease to recognise and analyse the situation fully. The management of the situation
often involves a multitude of different professions working in different organisations.
Many different treatments are needed. And
the evidence-base is very limited, so that
there is always considerable uncertainty
about prognosis and the most efficient management plan.
Nonetheless if all clinical staff and all specialist services used a holistic model of illness when undertaking their initial formu-
Holistic health care. Derick Wade.
November 25th 2009.
lation, it is likely that clinical decisions
would:
• be more appropriate, taking into account all relevant factors
• be more patient-centred, taking into account the person’s own views
• include an early referral onto an appropriate rehabilitation service (e.g. geratology)
At present this proposal is simply my opinion, but it is a testable hypothesis. The question is “Does ensuring that the initial clinical
encounter with a specialist hospital service includes collection and consideration of information across all domains of the holistic model of
illness lead to a better patient outcome including
overall well-being six months later?” In support of this hypothesis, several recent NICE
guidelines have set out general principles
that seem to endorse a patient-centred and
holistic approach [64][65][66].
One particular group of patients have a
complex illness, namely those with one of
the ‘functional illnesses’. Within this group
one might also include the large number of
people currently labelled as having ‘common mental disorders’ such as depression
and anxiety [67].
Functional illness is in many ways “the elephant in the room” or the ‘hidden iceberg’ in
the health service: there are many people
whose have functional illness; there is no
systematic way of recording this in healthcare systems; there are no specialist services;
and there is little research into treatment.
Consequently few people with functional
illness get a satisfactory service.
Using a holistic model of illness might help
this large group of patients. If there were a
general recognition and acceptance among
clinical staff that not all illness is due to underlying disease, then it is possible that the
true nature of the illness would be recognised much sooner. In fact early recognition
of the illness is not difficult [47], and at the
Page 23
very least would avoid the person being exposed to unnecessary and potentially harmful investigations and treatments.
More importantly, the available evidence
suggests that a comprehensive approach using several different interventions would
help most people:
• Acceptance by the person that there is
no hidden disease within their body
• Reduction of any exacerbating factors
identified that can be ameliorated
• Cognitive behavioural therapy,
• Anti-depressant drugs,
• Increasing exercise,
• Good sleep hygiene
Thirdly, the healthcare system should start
educating the public into a new way of considering illness. The effectiveness of a public education approach to altering the accepted model of a particular illness has been
shown for low back pain (a functional disorder) [46]; interestingly the public education also changed the behaviour of clinical
staff. Changing clinical culture should improve individual patient care.
Next it must be recognised that health care
is a process, not a single action. Few patients will follow a predictable pathway centred on one specific action. This is especially
true for patients who have complex problems:
• any patient who has a long-term
condition that fluctuates over time
• any patient with a condition with
several diseases
• any patient who requires a series of
specific treatments to achieve a good
outcome.
These patients now use the majority of
healthcare resources.
Thus in practice the healthcare system resource is rarely centred on a single constrained episode or organisation. Consequently commissioning and payment sys-
Holistic health care. Derick Wade.
November 25th 2009.
tems that focus on specific actions within
the process will rarely be an appropriate
way to manage the process, and they will
often lead to less efficient and/or less effective patient care as clinical behaviour adapts
to the payment system.
Financing and management systems need to
recognise that most people, especially those
with long-term and disabling conditions
will need multiple inputs from many organisations over a prolonged time. They
need to facilitate collaboration and cooperation across all boundaries, both within
healthcare and between healthcare and
other statutory and non-statutory organisations.
Fifth, this analysis shows that it is not possible to use specific criteria when considering
whether a patient should or should not be
seen by a neurological rehabilitation service.
The primary reason is that there may be
many factors from many different domains
that are influencing a person with a longterm condition but in any specific individual
only some of these will be amenable to action. However across the population of
people who will benefit from rehabilitation
there will be individuals with almost any
characteristic.
Thus if specific inclusion and/or exclusion
criteria are used then inevitably some people who would benefit from specialist
healthcare will be excluded.
There are many other reasons that have already been published [68], including a lack
of evidence and a high probability that even
for a specific intervention the criteria will
not have appropriate sensitivity and specificity.
Finally the holistic model of illness emphasises that being ill is a social phenomenon,
and emphasises that it is a person’s social
Page 24
context and personal context that probably
have the greatest influence upon behaviour.
Therefore healthcare should always aim to
return a person to their own context as soon
as possible, and health services should always be fully aware of the person’s context.
For example specialist services should develop out-reach and supportive services so
that more healthcare can be delivered to
more patients more locally [69][70]. Secondary care services should collect data about
a person’s home and social circumstances at
the earliest opportunity.
Moreover, one must recognise that leaving
the sick role and stopping ‘being ill’ is a
positive process and not simply inevitable.
Healthcare systems should be very concerned with ending illness not simply
through curing disease, but through ensuring that there are suitable resources in the
community to allow an ill person to develop
new roles in place of the sick role [71].
This means ensuring a range of suitable accommodation where someone can develop a
new or adjusted set of social roles, and ensuring that the person can get to suitable
venues to develop an active social life. Simply discharging someone home alone with
all physical care needed is ultimately inhumane and will often lead to the person returning into healthcare as their only escape.
Healthcare services need to work closely
with organisations responsible for more
general social policy. It is almost certainly
in their interest to do so in terms of reducing
healthcare costs.
Holistic health care. Derick Wade.
November 25th 2009.
Conclusion
A systematic holistic approach to illness and
healthcare can help in the understanding
and management of the problems faced by
individual patients. It emphasises that in
most illnesses there are many factors that
may contribute to the person’s experience
and that may be amenable to change when
helping the ill person. It also predicts that in
some people illness may arise without any
disorder within the person; these are functional illnesses. It emphasises that most
people with complex and/or long-term
conditions will need multiple interventions
from many professions working for different organisations delivered over long periods if we are to achieve the best outcomes.
This holistic model also suggests why and
how the current problems in the healthcare
system arise. It suggests that a competitive,
market-driven system based on episodes of
care and/or single specific actions is inevitably going to deliver worse health care; this
prediction is amply demonstrated by the
health care experiences in the United States.
The holistic healthcare model put forward
here is, as far as I know, the first one to be
defined and published. It undoubtedly can
be improved. However progress and improvement will only occur through defining
and publishing the theoretical models that
underlie healthcare. This is a first step in a
long journey.
Page 25
Acknowledgements
The ideas developed in this paper have
evolved over at least thirty years of working
with people with long-term neurological
conditions, and the first paper I wrote and
submitted to the British Medical Journal
(unpublished) concerned about functional
illness and was written in 1978. Their evolution has been assisted by a large number of
people who have commented on and disagreed with ideas, or who have posed clinical, research or management problems. I
thank them all.
I must specifically thank Professor Peter
Halligan. Over about fifteen years we discussed this model on a daily or weekly basis, and many of the improvements can be
traced back to our debates.
I must also acknowledge the support of my
wife Elizabeth and family Rachel, Rhiannon
and Nathaniel who, quite reasonably, must
be fed up with hearing me talk about this
model endlessly.
Finally I am grateful for the support given
by my employers and those who have paid
for my time; I have used some of my time to
develop and write about these ideas as can
be seen in my references. This includes the
University of Maastricht, Kings College
London, and the UK National Health Service.
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Holistic health care. Derick Wade.
November 25th 2009.
Page 33
Table
Lessons from WHO ICF model (based on ref 72)
Observation
Time
The time frames are different
at each level.
Health services
Hospitals and health services
focus on pathology.
Dependence at the level of
disability determines main
cost of long-term ill health.
Disability and context
Disability refers not only to
‘quantity’ (e.g. dependence
or otherwise) but also to
quality
Disability is strongly influenced by the goals of the patient (the personal context)
Comment
Change and management at levels of pathology and impairment are generally quick (hours/days), but change and management at levels of disability and handicap are generally slow
(weeks/months/years).
Therefore systems managing different levels should be separated; people with rehabilitation needs are inappropriately
placed in an environment focused on disease management
Hospitals are environmentally unsupportive of disability; hospital systems are procedurally set in short time frames
(hours/days); health service data is usually predicated on a definite diagnosis which is often not available, certainly at presentation.
Therefore it may be necessary to have two systems, one for diagnosing and managing pathology and one for diagnosing and
managing disability. Each would have different methods for
commissioning, and would use different data to guide management of the system.
Supportive care provided is main resource used in health care,
even in acute phase. The resources used are not related reliably
to pathological diagnosis.
Therefore payment for services should not be related to disease
diagnosis; they should relate to dependence and to rehabilitation treatments needed.
For some people it matters more how normally they act than
whether they can undertake an activity; the social implications
of altered behaviour may restrict that behaviour; measures rarely take account of the quality of task performance.
Therefore outcome measures should consider the perspective of
the person in addition to that of others.
All behaviour is goal-directed, and so disability cannot be considered ‘context free’; many factors including financial considerations may determine the activities undertaken by a patient.
Therefore all treatment should be patient-centred, based on a
good understanding of the patient’s own specific goals, interests
and concerns.
Holistic health care. Derick Wade.
Observation
Observed disability also depends upon the physical and
social context
Relationship between levels
The nature and extent of the
relationships between levels
are weak.
Causal relationships may extend in any direction, ‘up’ or
‘down’ the hierarchy.
November 25th 2009.
Page 34
Comment
How someone behaves is inevitably affected by environmental
factors and may be significantly constrained by the environment. The ‘environment’ includes the capabilities, wishes and
expectations of relevant others.
Therefore all interpretation of outcome requires information
about all aspects of context such as accommodation, time after
onset, presence of family etc.
The severity of a person’s illness (from their perspective) is rarely determined by the observed extent of disease. For example
patients may have ‘silent’ pathology (i.e. disease without symptoms or signs).
Therefore this gives scope for rehabilitation. It also implies that
measures of the extent of pathology are poorly related to the extent of disability in many cases.
The relationships are not all one way from pathology through to
handicap. Changes in behaviour may ‘cause’ pathology. For
example, electively not moving a shoulder may lead to the pathology of adhesive capsulitis (frozen shoulder).
Therefore one must not always simply seek the cause of pathology in cellular or genetic domains; the cause may be in the context. The ‘cause’ of most lung cancer is the availability of cigarettes.
Not all illness need start from A systems analysis of the model would predict that illness may
pathology
start at any level, and interact down the systems as well as up
the systems. Abnormal beliefs (part of personal context) may
cause as much disability as pathology (abnormal organ structure or function). Indeed it is noted that functional illness is
common in neurological practice, and this model both predicts
it and may help understand and manage it.
Prognosis depends upon pathology (if present)
Therefore management should focus on altering the perceptions, attitudes and behaviours of the ill person and those
around the ill person.
The prognostic field for an individual patient is usually determined by the specific disease, but the specific prognosis within
that field for a particular patient is usually related to impairments and other factors.
Therefore it is important that relevant expert doctors are
integral to all rehabilitation (they are also needed to confirm the
apparent, given main diagnosis and to diagnose any new clinical problems).
Holistic health care. Derick Wade.
Observation
Measurement and normality
Measures should only encompass items from one level.
November 25th 2009.
Page 35
Comment
It is invalid to add scores from items or measures covering domains from different levels.
Therefore any existing measures or proposed new measures
should be checked before use or development.
The metric against which structure, function, behaviour or performance is judged varies:
‘Normal’ becomes much less
easy to define, and becomes
increasingly personal
Pathology Structure or function measured against any human, with some
allowance for age and gender.
Impairment Structure or function measured against humans matched for
age, gender, and other demographic characteristics.
Activities Behavioural performance and repertoire measured against:
• Socially normative behaviour for some activities
• Previous personal behaviour for some activities
• Desired behaviour for some activities
• Expected (e.g. by family) behaviour for some activities
Participation Social role performance and social position measured against:
• Socially valued and expected roles for whole society
• Culturally valued and expected roles for local, personal society
• Personally valued and expected roles
Miscellaneous
The terminology used all as- There are currently no good words for the opposite of impairsumes abnormality
ment, disability or handicap.
Interventions may occur at
many points
The ‘new’ terminology of limitations on activities and participation overcomes some of this, though there is still no obvious
opposite to impairment.
While removal of the prime cause of an illness is the ideal, and
this prime cause will often be at the level of pathology, interventions at other points are often also effective, especially when
there is no pathology or when pathology cannot be altered.
Therefore payment systems that only reward one specific intervention are an invalid way of funding the management of longterm conditions and will certainly distort good practice and
make rehabilitation less efficient and effective.